Nickel allergy and IN BRIEF

Readers will develop an understanding of

orthodontics, a review the background of nickel allergy and its

PRACTICE
epidemiology in orthodontics.
Readers will learn the signs and symptoms

and report of two cases

of a nickel allergy in orthodontics.
Readers will have an understanding
of making a diagnosis and alternative
methods to treat orthodontic patients
who have developed an intra-oral nickel
J. Noble,1 S. I. Ahing,2 N. E. Karaiskos,3 W. A. Wiltshire4 allergy due to orthodontic appliances.
Two detailed real life cases are presented.
VERIFIABLE CPD PAPER

Nickel is a common component in many orthodontic materials. An allergy to nickel is commonly seen in the population,
more frequently in women. This allergy has increased with the more frequent use of nickel containing jewellery and in
traoral piercings. As a result, this allergy can be expected to be more readily encountered in dental practice. Possible allergy
to nickel should be a question in the initial patient health history questionnaire. The dental practitioner should be mindful
of this allergy during the course of orthodontic treatment, and know how to diagnose a nickel allergy if it appears and
subsequent action in treatment and referral if it is suspected. This paper provides a summary of nickel allergy, its epide
miology, diagnosis and recommendations and alternatives to treatment. A detailed description of two cases where it was
discovered in orthodontic patients is also reported.

INTRODUCTION
especially with the increased preva
Orthodontists are sometimes required to
treat patients with an allergy to nickel.
This is a concern for the orthodontist
because it is present in a vast array of
materials frequently used in orthodon
tics. Nickel is the most common compo
nent of the super-elastic nickel-titanium
(Ni-Ti) archwires used during the initial
levelling and aligning phase of ortho
dontic treatment with a concentration of
47-50%.1 It is also a component in stain
less steel (present in both archwires and
brackets), representing approximately
8% of the alloy. Extraoral orthodon
tic appliances such as the outer bows
of headgears contain nickel and may
also elicit a response on the skin.2,3 The
sensitisation and allergy to nickel is
an increasing concern in orthodontics,
1*,3
Senior Graduate Orthodontic Residents, Department
of Preventive Dental Sciences, Division of Orthodontics,
2
Associate Professor, Specialist in Oral Medicine and
Pathology, Division of Oral Diagnosis and Radiology,
4
Professor and Head of Orthodontics and Head of the
Department of Preventive Dental Science, University of
Manitoba, Winnipeg, Manitoba, Canada
*Correspondence to: Dr James Noble
Email: umnoble@cc.umanitoba.ca
Refereed Paper
Accepted 1 March 2008
DOI: 10.1038/bdj.2008.198
British Dental Journal 2008; 204: 297-300
women and 20% of women between the
lence of nickel containing jewellery and
oral piercings.4
Immune response
The response by the immune system to
nickel is usually a Type IV cell mediated
delayed hypersensitivity also called an
allergic contact dermatitis. It is mediated
by T-cells and monocytes/macrophages
rather than antibodies and consists of
two phases. The rst phase, or sensitisa
tion, occurs when nickel initially enters
the body. There is usually no response
present at this time but the immune
system is primed or sensitised for an
allergic response. The major sensitisa
tion routes are nickel-containing jewel
lery and foods. Foods that are high in
nickel include chocolate, soy beans, nuts
and oatmeal. A response, or the elicita
tion phase, is in the form of a contact
mucositis or dermatitis that occurs dur
ing re-exposure to nickel and develops
over a period of days or rarely up to
three weeks. If nickel is leached from
orthodontic appliances, this Type IV
hypersensitivity reaction can occur.5
Epidemiology
Nickel allergy occurs more frequently
than allergy to all other metals com
bined.3 It is estimated that 11% of all
ages of 16 and 35 years have a sensitiv
ity to nickel.6-8 The sensitivity of males
is only 2%, likely due to the decreased
contact of nickel from jewellery. Fortu
nately, most individuals who have nickel
sensitivity do not report adverse clinical
manifestations to orthodontic appliances
containing nickel. It is estimated that
the occurrence of a harmful response
by patients to nickel is 0.1-0.2%.9 It is
thought that a much greater concentra
tion of nickel in the oral mucosa than
the skin is necessary to elicit an aller
gic reaction.10 Furthermore, the inci
dence of an allergic response to stainless
steel orthodontic brackets has not been
reported, however, there have been some
reported cases.4,11-14
Nickel leaching of orthodontic bands,
brackets and stainless steel or Ni-Ti
archwires has been shown in vitro to
maximally occur within the rst week
and then decline thereafter.15 This coin
cides with the approximate time frame
for Type IV hypersensitivity reactions.
Saliva or certain intraoral conditions
such as foods, oral hygiene products
and uoride may potentially corrode the
nickel in the alloy and release it onto the
oral mucosa. Ni-Ti orthodontic wires in
combination with uoride media have
been shown to release signicantly more

BRITISH DENTAL JOURNAL VOLUME 204 NO. 6 MAR 22 2008 297

2008 Nature Publishing Group
PRACTICE
nickel ions in articial saliva.16 Also, Ni-
Ti archwires, especially when they con-
tain copper, have been shown to corrode
in the presence of uoride mouthwash.
This has implications not only in the
development of contact sensitivity reac
tions but also in decreased mechanical
properties of the wire.17
The amount of corrosion from differ
ent alloys, however, has not been clini
cally demonstrated. Factors including
intra-oral temperature, pH, salivary
composition, duration of exposure,
wear of the wire due to friction from
sliding mechanics, abrasion, presence
of solder, strain of the wire and most
importantly the amount of nickel that
is leached are factors determining the
concentration of nickel present from
a particular appliance.18 Other factors
predisposing patients to nickel allergy
include genetics19 and the presence of
certain major histocompatability com
plex haplotypes.20 Nickel sensitivity
has also been found to be higher in
asthmatic patients.21,22
Diagnosis
The diagnosis of a response to nickel in
the oral mucosa is more difcult than
on the skin. A known allergy to nickel
should be determined when the patient
completes the medical questionnaire or
during a verbal medical history review.
The patient should then be forewarned
of a possible response to the nickel in
orthodontic appliances, particularly to
the initial archwire placed. If a nickel
allergy is still in question, a diagnosis
can be conrmed by a dermatologist by
conducting a cutaneous sensitivity test
called a patch test using 5% nickel sul
phate in petroleum jelly.23
Oral clinical signs and symptoms of
nickel allergy can include the following:
a burning sensation, gingival hyper
plasia,24 labial desquamation, angular
chelitis, erythema multiforme, peri
odontitis, stomatitis with mild to severe
erythema, papular peri-oral rash, loss of
taste or metallic taste, numbness, sore
ness at side of the tongue.25-30 It should be
noted that symptoms can occur without
signs. Extraoral manifestations of nickel
allergy may have an intraoral origin.31
Before the diagnosis of nickel hyper
sensitivity can be made, other lesions
298
should be eliminated including candi-
diasis, herpetic stomatitis, ulcers due to
mechanical irritation and allergies to
other materials including acrylic.32
The nickel leachability test consists of
solutions of 1% dimethylglyoxime and
10% ammonium hydroxide solutions
which are mixed just prior to use. A
moistened Q-tip with the combined solu
tion is used for swabbing the arch wires
in vitro or samples can be immersed in
the mixed solution. A positive test for
nickel leachability is a colour change to
red. A nickel coin is used as the posi
tive control. While a positive result
can be supportive of nickel leachabil
ity from the suspected dental material,
a negative test is always overridden by
the clinical response to removal of the
material. It could also represent a false
negative which did not take into account
unique intraoral conditions that may
alter leachability.
Treatment
If intra-oral signs and symptoms are
present and a diagnosis of nickel hyper
sensitivity is established, the nickel tita
nium archwire should be removed and
replaced with a stainless steel archwire
which is low in nickel content or prefera
bly a titanium molybdenum alloy (TMA),
which does not contain nickel. Stainless
steel is slightly less expensive than Ni-Ti
archwires while TMA is slightly more.
Resin coated Ni-Ti wires are also an
option. These resin-coated wires have
had their surface treated with nitrogen
ions, which forms an amorphous surface
layer. Manufacturers claim that this
results in an increase in corrosion resist
ance and decreased amount of leaching
of nickel, more so than both Ni-Ti and
stainless steel wires.33
Most patients who develop a reaction
to Ni-Ti archwires subsequently tolerate
stainless steel without a reaction.34 This
is believed to be a result of the nickel
being tightly bound to the crystal lat
tice of the alloy, rendering them unable
to be leached into the oral cavity. Stain
less steel has been shown to release low
amounts of nickel in articial saliva
or sweat which could help account for
its low allergenicity.35 In the rare event
that the patient continues to manifest
an allergic reaction, all stainless steel
2008 Nature Publishing Group
archwires and brackets should be
removed. If any severe allergic reaction
develops, the patient should be referred
to a physician to be treated with anti
histamines, anaesthetics or topical cor
ticosteroids.36 Attempts should be made
to complete orthodontic treatment with
TMA, bre-reinforced composite, pure
Ti or gold-plated wires.
The most commonly used orthodon
tic brackets that do not contain nickel
include ceramic brackets produced
using polycrystalline alumina, single
crystal sapphire, and zirconia. Other
nickel-free alternative brackets include
polycarbonate brackets made from plas
tic polymers, titanium brackets and gold
brackets. Another alternative for certain
treatments is the use of plastic aligners
such as Invisalign.
CASE REPORT 1
A 31-year-old female presented request
ing orthodontic treatment with a chief
concern that she had a unilateral poste
rior crossbite. Upper ceramic and lower
stainless steel brackets were bonded and
0.014 Ni-Ti archwires were inserted.
After three days, the patient reported that
her lips had an anaesthetic-like feeling.
She had also been asked by her friends
if she had received collagen injections
into her lip due to the swelling that was
apparent. Clinical examination revealed
swollen lips and the development of an
interlabial gap when her upper and lower
lips were at rest. General sensation was
within normal limits and there were no
intraoral lesions present. The patient did
not report any adverse taste sensation or
pain. The Ni-Ti archwires were immedi
ately removed and a stainless steel wire
was inserted. The patient reported reso
lution of symptoms within ve hours of
removal of the Ni-Ti archwire. A nickel
leaching test was undertaken with the
orthodontic wires used and also with the
same manufacturers unused upper and
lower 0.014 Ni-Ti archwires. The results
came back negative for leachable nickel.
This indicated that while contact with
the nickel-containing alloy initiated the
patients symptoms, the nickel was not
leached out under laboratory test con
ditions. However, nickel leaching tests
under conditions of contact with saliva,
food or oral hygiene products was not
BRITISH DENTAL JOURNAL VOLUME 204 NO. 6 MAR 22 2008

undertaken. Clinical examination after
three days of removal of the archwires
demonstrated that lip competence had
returned. The patients lips no longer
appeared swollen and the clinical anaes
thetic-like symptoms did not return.
After three months of treatment using a
combination of stainless steel and TMA
wires, the symptoms had not returned. A
re-challenge with a Ni-Ti archwire was
not performed.
CASE REPORT 2
A 15-year-old female was evaluated
by an oral pathologist for oro-pharyn
geal itching, sandpaper-like roughness,
bumps, burning and strong discomfort
which had persisted for six months. The
symptoms occurred in daily episodes of
mild to moderate intensity lasting 15-60
minutes but with occasional severe epi
sodes, which were of sufcient intensity
to reduce the patient to tears. No initial
or ongoing precipitating factors could be
recalled. Contact with cold foods such as
ice cream and warm showers seemed to
help but in a transient manner.
She was allergic to dust, pollens, cats,
sh and seafood with reactions ranging
from rhinitis to anaphylaxis ( sh and
seafood). She did not report a history of
allergy to any metal. Evaluation by an
oto-rhinolaryngologist was unremark
able and included CT imaging and cul
tures. She was taking contraceptive pills
for acne.
On examination, orthodontic brack
ets and archwires were in place but no
mucosal changes could be demonstrated.
Management choices were either a
symptom diary without intervention or
empirical chronic neuropathic pain med
ications such as capsaicin or a low dose
antidepressant. She declined medication
and at six month follow up, her diary
revealed that orthodontic treatment had
been initiated just prior to the onset of
her symptoms. Only at this point was a
metal allergy considered. The Ni-Ti arch
wires were replaced with stainless steel.
Her previous daily symptoms for the past
year resolved within two weeks and she
was symptom free at a subsequent two
month follow up. She has not revisited
the clinic and is presumed to be in an
asymptomatic state at the time of writing
one and a half years later.
BRITISH DENTAL JOURNAL VOLUME 204 NO. 6 MAR 22 2008
DISCUSSION
In both cases the diagnosis of nickel
contact hypersensitivity was supported
by the onset of symptoms shortly after
the placement of Ni-Ti archwires and
their rapid resolution upon removal. In
neither case was a re-challenge or skin
testing undertaken. In Case 1 the diag
nosis and management was facilitated
by the labial swelling while in Case 2 the
(a) absence of clinical signs (b) negative
history of metal allergy and (c) no initial
association with the onset of orthodontic
treatment provided more of a diagnos
tic challenge. In Case 2 the intermittent
nature of her symptoms is theorised to
be due to periods of increased nickel
leachability from some daily altera
tion of the intra-oral environment (eg
uoride exposure, food composition).
The absence of mucosal change is still
compatible with nickel hypersensitivity
since mucosal symptoms without signs
have been reported. Symptom reduction
by cold foods and warm showers could
be due to activation of the large diam
eter, low threshold bres (Gate Control
Theory of Pain). An atopic history may
be signicant as a predisposing factor. A
potential sensitisation mechanism with
regard to dietary nickel or body jewel
lery was not explored.
CONCLUSIONS
Though an allergic response to nickel
in the oral mucosa from nickel con
taining orthodontic appliances is more
infrequent than from nickel contact on
the epidermis, it can occur, particularly
in females.37 If nickel-related intraoral
clinical signs and symptoms appear,
the orthodontist should be prepared to
undertake or continue treatment without
the use of Ni-Ti wires and even without
stainless steel. These two cases illustrate
that clinical signs of nickel hypersensi
tivity may be subtle or absent. The fre
quency of orthodontic treatment and the
common use of nickel containing ortho
dontic materials raises the interesting
question of whether orthodontic treat
ment may act to increase or decrease
the burden of nickel hypersensitivity
in the population. There is evidence
that oral exposure to nickel may induce
immunologic tolerance to nickel and
thereby reduce the incidence of nickel
2008 Nature Publishing Group
PRACTICE
allergies.38-42 Nevertheless when clinical
signs or symptoms presumed to be due
to nickel hypersensitivity are distress
ing to patients there are many choices
of materials available to the orthodontist
as alternatives.
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Erratum
Summary of: A survey of the workload of dental therapists/hygienist-therapists employed
in primary care settings (BDJ 2008; 204: 140-141)
It has been brought to our attention that an error was printed in the Comment section of the above research summary. Column
2 line 4 on page 141 should read their dually-qualied therapists as hygienists? The author apologises for the transposition
of these key words in the version originally published.
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